The Connecticut Opioid REsponse Initiative

1 The Connecticut Opioid REsponse InitiativeOctober 5, 2016 The Connecticut Opioid REsponse Initiative1 The Connecticut Opioid REsponse InitiativeOctober 5, 2016 The genesis of this strategic plan was Governor Dannel P. Malloy s charge to the Alcohol and Drug Policy Council (ADPC), a statewide stakeholder group, to comprehensively address Connecticut s Opioid crisis. Governor Malloy engaged the Connecticut Opioid REsponse (CORE) team to supplement and support the work of the ADPC by creating a focused set of tactics and methods for immediate deployment in order to have a rapid impact on the number of Opioid overdose deaths in Connecticut . He asked the CORE team to focus on evidence-based strategies with measurable and achievable outcomes. Finally, the Governor requested that the CORE team s strategic plan be cognizant of Connecticut s new economic reality while not shying away from proven strategies that may not be funded currently. Accordingly, the CORE team s strategic plan lays out a series of actions designed to rapidly reduce Opioid -related overdose deaths in Connecticut .

2 As a strategic , tactical document, it does not represent a broader strategy to address many of the complex factors that have produced the Opioid crisis. The CORE team will continue to work with the ADPC as they lead the state s comprehensive REsponse to the Opioid crisis and collaborate on future challenges as they Connecticut Opioid REsponse Initiative2 Mission: To decrease the adverse impact of opioids on Connecticut residents, with an immediate emphasis on reducing overdose : To identify sources of current Connecticut data and to apply evidence to most urgently and efficiently guide efforts to achieve our stated mission. Values: Evidence, timeliness, respect, access, collaboration, and measurable high-impact the Connecticut Opioid REsponse (CORE) Initiative is: A mechanism to articulate data-driven and evidence-based medical, public health and policy strategic initiatives related to treating Opioid use disorder, reducing overdose events and a means for achieving these initiatives.

3 To help focus efforts, the CORE Initiative will serve as a vehicle to articulate tactics and methods that are most likely to help achieve these aims in the short term. To help monitor progress, the CORE Initiative provides measures or metrics that can be tracked to assess progress over and state representatives and agencies have put forth reasoned and informed recommendations to help address Opioid use, addiction and overdose over the past year. Major components of these are outlined in Table 1. Table 1. Recommendations from stakeholdersRecommendationNational Governors Association Road Map for StatesSenator Blumenthal, Opioid Addiction, A call to actionDepartment of Mental Health and Addiction Services, Triennial State Substance Abuse plan , Opioid Annex, 2016 Alcohol and Drug Policy CouncilExpand access to naloxoneXXXXP revent abuse of opioids through educationXXXE xpand access to treatment with medicationsXXXXE xpand access to treatment with medications in criminal justice settings XXXXD ivert individuals arrested for Opioid related crimes into treatmentXXXP romote improved prescriber adherence to guidelines XXXXE nhance access to non- Opioid treatments for painXXThe CORE Initiative will not be a reiteration of compre-hensive plans and recommendations outlined by these federal and state representatives.

4 Nonetheless, the CORE Initiative provides methods to track the extent to which some of these recommendations have been achieved. To address the current urgent situation, the CORE initia-tive avoids a listing of strategies that are less likely to have short-term impact. Although these are important The Connecticut Opioid REsponse Initiative3and necessary, they have been articulated by others, they may have less compelling scientific evidence to support them or are expected to have less of an immediate impact on overdose Some of these are included in the CORE Appendix to ensure that they inform overarch-ing and long-term efforts. The CORE Initiative does not address strategies or tactics as they relate to reductions in supplies of illegally trafficked opioids as these are under the purview of federal, state and local law enforcement agencies. Finally, the CORE Initiative is not intended to serve as comprehensive guidance on the use of opioids for acute or chronic pain.

5 Pain and addiction are distinct clinical entities. While these sometimes occur in the same individual, guidelines for the use of opioids for acute and chronic pain have been note about language: To address the unfortunate and unwarranted stigma associated with Opioid use and addiction it is necessary to articulate basic concepts to help avoid unintentional adverse connotations. We will use person-first language and accurate health terminology and avoid language that can be stigmatizing or For instance, we would refer to individuals as people with an addiction, instead of addicts, we would describe indi-viduals as abstinent rather than clean, and we would refer to methadone and buprenorphine as medications rather than drugs. The use of Opioid analgesics ( prescription opioids) for acute and chronic pain: Opioid analgesics are import-ant medications that can provide relief for acute pain, for pain in individuals receiving palliative care and for some individuals with chronic While some individuals have decreased pain and improved function while receiving opioids for chronic pain, the scientific evidence indicates that this may not occur for many In addition, the scientific evidence indicates that by taking opioids for chronic pain, some individuals are placed at increased risk for addiction, overdose, and other adverse Finally, the dramatic rise in the rate of Opioid prescrib-ing for pain has resulted in an unintended overabundant supply of these medications that can be diverted and lead to misuse and addiction.

6 The need to strike a balance between the benefits achieved by some individuals and the devastating outcomes in others has spurred pain medicine specialty societies and the Centers for Disease Control and Prevention (CDC) to develop guidelines to help ensure adequate access to these medications while minimizing risks and adverse public health ,4 The 2016 CDC guideline encouraged risk benefit assessment at all Opioid dosage levels, and reassessment of benefit of risk at doses greater than 50 milligrams morphine equivalents (MME) per day, and an avoidance of doses greater than 90 MME per day, without , Opioid use disorder and its treatment: Addiction is a chronic illness characterized by changes in brain chemistry and function. The medical term for Opioid addiction is Opioid use disorder. It is important to distin-guish Opioid use disorder from the physical dependence that typically occurs when individuals take opioids for medical conditions.

7 The primary factor used in making this distinction is the lack of control over the use of opioids that is seen in individuals with Opioid use disorder, but not in those who only have physical dependence. This loss of control can lead to behaviors that individuals otherwise would avoid, including chronic nature of Opioid use disorder mandates a long-term view on treatment, not unlike the view that is taken in other medical conditions such as diabetes, hypertension or depression. As with other chronic medical conditions, there is a spectrum from mild to severe and the cause is rooted in genetic and environmental factors. Prevention, especially among youth, can have important long-term benefits. Some psychiatric and medical conditions are seen at an increased rate among individuals with Opioid use disorder and require concurrent treatment. Co-use of other addictive substances such as nicotine, marijuana, alcohol, cocaine and benzodiazepines can also occur and require specific treatments.

8 Chronic medical conditions such as Opioid use disorder are typically not cured, but rather can be in remission. Recovery, an important concept that connotes a holistic and sometimes spiritual process, can be challenged by relapse. Unfortunately, there are no rapid or short-term treatments for chronic medical conditions such as Opioid use disorder, and control or remission are the medical terms used to reflect a lack of The Connecticut Opioid REsponse Initiative4substantial influence of the medical condition on one s daily function and health. Long-term treatment and monitoring are essential components of care for Opioid use disorder. As with other chronic medical conditions, the intensity of the treatment services should be matched to the severity of the disorder. The levels of care outlined by the American Society of Addiction Medicine (ASAM) provide a useful guide and include (1) early intervention, (2) outpatient, (3) intensive outpatient/partial hospitalization, (4) res-idential/inpatient, and (5) medically managed intensive Not all individuals require or benefit from inpatient (hospitalization) or detoxification.

9 The changes in brain chemistry and function that occur and persist in individuals with Opioid use disorder mean that short-term management such as detoxification is not a stand-alone treatment. In fact, detoxification alone is associated with high rates of relapse and places individuals at risk for overdose due to a lowered level of physical For many individuals with Opioid use disorder, treatment should be initiated with an outpatient or intensive out-patient treatment on the medical evidence, a range of local, state, federal and international expert organizations including the World Health Organization, the White House Office of National Drug Control Policy, the Surgeon General, the National Institutes of Health, the Department of Health and Human Services, and the National Governor s Associ-ation20-24 agree that the most effective treatment for Opioid use disorder involves medications such as buprenorphine and methadone in combination with counseling and sup-port services.

10 Long-standing institutions such as the Betty Ford and Hazelden Foundations that have historically focused on non-medication treatments for substance use disorders have incorporated buprenorphine into their treatment programs. The provision of methadone for the treatment of Opioid use disorder is restricted to opi-oid treatment programs (OTPs) regulated by the federal government. Buprenorphine can be provided through OTPs or by office-based prescribers who have completed appropriate training in accordance with the Drug Addiction Treatment Act of 2000 (DATA 2000).25 Expanded access to and increased use of methadone and buprenorphine have resulted in dramatic decreases in Opioid overdose mortality in a cost-effective ,26-28 Naltrexone, an approved treatment for Opioid use disorder, may have benefits in select settings and individuals but does not prevent symptoms of withdrawal or address ,30 However, compared to methadone and buprenorphine, naltrexone s efficacy is less than methadone and buprenor-phine and there is less data demonstrating its impact on reducing overdose death, human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission, and other adverse consequences associated with Opioid use as methadone and Naloxone for reversing Opioid overdose: Naloxone is a medication that reverses and blocks the effects of opioids.